ANNUAL INFLUENZA REPORT,

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1 Manitoba Health, Healthy Living and Seniors ANNUAL INFLUENZA REPORT, July 1, 214 June 3, 215 Epidemiology & Surveillance Public Health Branch Public Health and Primary Health Care Division December, 215

2 epireport INFLUENZA TABLE OF CONTENTS Executive Summary... 5 Reporting Weeks... 6 Acronyms... 6 Introduction... 7 Syndromic Surveillance... 8 Sentinel Surveillance of ILI... 8 Health Links Info Santé... 9 Laboratory Reporting... 1 Influenza A... 1 Influenza B RHAs Hospitalizations, ICU Admissions and Deaths Laboratory-confirmed Outbreaks Immunizations Uptake Providers Adverse Events Following Immunization (AEFI) Antiviral Dispensing Strain Characterization and Antiviral Resistance Discussion Page 2 of 26

3 epireport INFLUENZA LIST OF FIGURES Figure 1 Percent of patient visits to sentinel physicians due to ILI by week and season... 8 Figure 2 Calls to Health Links Info Santé by week and season... 9 Figure 3 Types of calls to Health Links Info Santé by week in Figure 4 Laboratory-confirmed influenza A cases by week and season Figure 5 Influenza A cases by week in and historical average Figure 6 Incidence rate (/1,) of influenza A by age group and season Figure 7 Laboratory-confirmed influenza B cases by week and season Figure 8 Influenza B cases by week in and historical average Figure 9 Incidence rate (/1,) of influenza B by age group and season Figure 1 Incidence rate (/1,) of influenza A by region and season Figure 11 Figure 12 Figure 13 Influenza associated hospitalizations, ICU admissions, and deaths by week in Influenza A associated hospitalizations, ICU admissions, and deaths by age group in Influenza B associated hospitalizations, ICU admissions, and deaths by age group in Figure 14 Outbreaks of influenza A and B by week in Figure 15 Influenza immunization uptake rate (%) by age group in Figure 16 Influenza immunization uptake rate (%) by region and age group in Figure 17 Influenza vaccine doses by provider type and month in Figure 18 Units of Oseltamivir dispensed by week in Page 3 of 26

4 epireport INFLUENZA LIST OF TABLES Table 1 Incidence rate (/1,) of influenza A and B by RHA in Table 2 Hospitalizations, ICU admissions and deaths by influenza type in Table 3 Influenza immunization uptake rate (%) by region and age group in Table 4 Influenza vaccine doses by provider type and month in Table 5 Influenza vaccine doses (%) by provider type and client age group in Table 6 Adverse events following influenza immunization by age group in Table 7 Types of adverse events following influenza immunization in Table 8 Levels of care required and outcomes for adverse events following influenza immunization in Table 9 Strain characterization of influenza isolates in Manitoba and Canada in Table 1 Antiviral resistance of influenza isolates in Manitoba and Canada in Page 4 of 26

5 epireport INFLUENZA Executive Summary Seasonal influenza can cause severe morbidity and mortality at extremes of life. In Manitoba, influenza is a reportable disease under The Public Health Act. Routine monitoring of influenza is performed by Manitoba Health, Healthy Living and Seniors (MHHLS) through a variety of mechanisms. Surveillance data are reported in a weekly bulletin during an influenza season. This end of season report provides an overview for the influenza season between July, 214 and June, 215 in Manitoba. The influenza season in Manitoba was characterized with the highest morbidity and mortality since the 29 influenza A(H1N1) pandemic season. There were prolonged severe health outcomes among older Manitobans. Influenza A activity started to increase at the beginning of December and peaked shortly after Christmas. A high level of activity was maintained until the end of January. Influenza B activity started to increase in February and peaked at the end of March, which resulted in a prolonged and low level of influenza activity until mid May. Two factors contributed to the high disease activity level in the season. First, the predominant circulating subtype in was influenza A(H3N2), a strain that typically affects the older population and causes higher levels of morbidity compared to other strains. Second, the vaccine effectiveness against the circulating influenza A(H3N2) strain during this season was low due to a mismatch between the vaccine and the predominant circulating virus as a result of significant antigenic drift in the circulating influenza A virus. Page 5 of 26

6 epireport INFLUENZA Reporting Weeks Time trends in this report were analyzed by epidemiology week, a schedule used by the national FluWatch program coordinated by the Public Health Agency of Canada (PHAC). Week Start End Week Start End Jun-14 5-Jul Jan-15 1-Jan Jul Jul Jan Jan Jul Jul Jan Jan Jul Jul Jan Jan Jul-14 2-Aug Feb-15 7-Feb Aug-14 9-Aug Feb Feb Aug Aug Feb Feb Aug Aug Feb Feb Aug-14 3-Aug Mar-15 7-Mar Aug-14 6-Sep Mar Mar Sep Sep Mar Mar Sep-14 2-Sep Mar Mar Sep Sep Mar-15 4-Apr Sep-14 4-Oct Apr Apr Oct Oct Apr Apr Oct Oct Apr Apr Oct Oct Apr-15 2-May Oct-14 1-Nov May-15 9-May Nov-14 8-Nov May May Nov Nov May May Nov Nov May-15 3-May Nov Nov May-15 6-Jun Nov-14 6-Dec Jun Jun Dec Dec Jun-15 2-Jun Dec-14 2-Dec Jun Jun Dec Dec Jun-15 4-Jul Dec-14 3-Jan-15 Acronyms AEFI CPL DPIN E&S EIA ICU ILI MHHLS MIMS MOH NML PCR PHCC PHAC RHA Adverse event following immunization Cadham Provincial Laboratory Drug Programs Information Network Epidemiology and Surveillance, unit of MHHLS Enzyme immunoassay Intensive Care Unit Influenza like illness Manitoba Health, Healthy Living and Seniors Manitoba Immunization Monitoring System Medical Officer of Health National Microbiology Laboratory Polymerase chain reaction Provincial Health Contact Centre Public Health Agency of Canada Regional Health Authority Page 6 of 26

7 epireport INFLUENZA Introduction This report details the influenza activity in Manitoba for the season between July 1, 214 and June 3, 215. Epidemiology and Surveillance (E&S) in Public Health Branch of MHHLS routinely monitors and reports the disease activity during each influenza season. In the season, the highest influenza morbidity and mortality since the 29 influenza A(H1N1) pandemic season was observed. Overall: There were 1,75 influenza A cases and 217 influenza B cases with laboratory confirmation. The predominant circulating subtype this season was influenza A(H3N2), a strain that typically affects the older population and causes higher levels of morbidity. Consequently, older people were affected the most this season. The influenza A season peaked in Week 53 (December 28, 214 January 3, 215) and the influenza B season peaked in Week 13 (March 29, 215 April 4, 215). There were 35 hospitalizations associated with laboratory-confirmed influenza diagnosis, of which 62 resulted in an intensive care unit (ICU) admission. Among those in-patients, 5% were over 7 years of age. Additionally, there were 48 influenza associated deaths, of which 37 were 8 years of age and older. There were 15 laboratory-confirmed influenza outbreaks reported, which mostly occurred in long-term care facilities. The provincial vaccine uptake in was 22.3%, which was similar to the vaccine uptake in Pharmacists delivered 17% of all influenza vaccine doses administered. Drifting of the influenza A(H3N2) strain resulted in a vaccine mismatch and near zero vaccine effectiveness against the predominant circulating influenza A(H3N2) strain. The rate of adverse events following the seasonal influenza immunization was 13.1 episodes per 1, doses administered, which was lower than in A variety of data sources and surveillance indicators were evaluated to identify and monitor the arrival of influenza, intensity of activity, and the characteristics of those infected, as well as severity and trends. Surveillance data analyzed for this report include: Syndromic surveillance a. Sentinel surveillance of influenza-like illness (ILI) in the community b. Influenza-related calls to Health Links Info Santé Laboratory reports of influenza infections Hospitalizations, ICU admissions, and deaths associated with laboratory-confirmed influenza diagnosis Laboratory-confirmed influenza outbreaks Influenza immunizations including vaccine uptake, service providers, and adverse events following immunization Influenza antiviral dispensing Strain characterization of influenza and antiviral resistance. Page 7 of 26

8 ILI rate (/1 patient visits) epireport INFLUENZA Syndromic Surveillance Sentinel Surveillance of ILI Manitoba participates in FluWatch, the Canada s national surveillance system co-ordinated by PHAC, which monitors the spread of influenza and ILI on a year-round basis. FluWatch consists of a network of laboratories, hospitals, doctor s offices and provincial and territorial ministries of health. ILI in the general population is defined as: Acute onset of respiratory illness with fever and cough and with one or more of the following: sore throat, arthralgia, myalgia, or prostration which is likely due to influenza. In children under the age of 5, gastrointestinal symptoms may also be present. In patients under 5 or over 65 years of age, fever may not be prominent. In Manitoba, there are sentinel physicians throughout the province reporting to FluWatch weekly. Sentinels can also opt into the voluntary swabbing component of the program. This consists of the submission of either two posterior pharyngeal swabs or two nasopharyngeal swabs within 48 hours of symptom onset from patients presenting with ILI. Requisitions, swabs, and antiviral transport media are available from Cadham Provincial Laboratory (CPL). E&S receives weekly reports from FluWatch which present the ILI rate for Manitoba and for each of the participating sentinel physicians. In , there were 27 sentinel physicians recruited in Manitoba. During the season, ILI consultations occurred year-round and peaked in Week 53 (December 28, 214 January 3, 215) when approximately 13% of patient visits were due to ILI. Note that the ILI rate this season during the epidemic was lower than those observed in and , the two influenza A predominant seasons (Figure 1). This is counterintuitive to the fact that the influenza activity level this season was higher than the two previous seasons / / / / Figure 1 Percent of patient visits to sentinel physicians due to ILI by week and season Page 8 of 26

9 Calls to HL-IS epireport INFLUENZA Health Links Info Santé Health Links Info Santé is one of 3 inbound and outbound calling programs offered by the Provincial Health Contact Centre (PHCC). Implemented in 1994, this bilingual program was the first telephone, nurse-based triage system in Canada. It is operated by Misericordia Health Centre in partnership with MHHLS and Winnipeg Regional Health Authority (RHA). A staff of 8 full- and parttime registered nurses work for this triage system that answers calls 24 hours a day, seven days a week, 365 days a year. Interpreters are available for over 1 different languages. During each call, a nurse will obtain information about symptoms and follow clinical protocols on the computer screen to offer advice on whether to treat the symptoms at home, see a family doctor, or visit an emergency room. Calls range from concerns about abdominal pain to influenza virus symptoms. 1 When callers phone Health Links Info Santé and select Influenza Service, they are given an option to select information on: (1) the groups of individuals who are at an increased risk of serious illness, (2) how to arrange an influenza vaccine, (3) the annual influenza immunization campaign, or (4) the management of influenza and its potential complications. E&S receives the aggregate data from Health Links Info Santé Influenza Service weekly. Similar to previous seasons, there were two clear peaks in influenza-related calls to Health Links Info Santé in (Figure 2). The first peak in Week 43 (October 19 25, 214) coincided with the onset of the annual influenza immunization campaign. The proportion of calls attributed to questions related to the influenza clinics and influenza program also peaked around the same time (Figure 3). The second and much lower peak occurred in Week 53 (December 28, 214 January 3, 215) when influenza activity peaked. Note that the two peaks this season were much lower than in the three previous seasons / / / / Figure 2 Calls to Health Links Info Santé by week and season 1 Source: Page 9 of 26

10 epireport INFLUENZA % 9% 8% 7% 6% 5% 4% 3% 2% 1% % Flu Clinic Influenza Program Flu Management Flu Criteria Figure 3 Types of calls to Health Links Info Santé by week in Laboratory Reporting Reports of influenza nucleic acid detection, culture isolation and enzyme immunoassay (EIA) detections from CPL (and occasionally other labs) are routinely forwarded to E&S within 24 hours of confirmation. Within this report, the specimen collection date was used to assign a case to the reporting week. Therefore, this report contains positive laboratory reports of tests with specimen collection dates between July 1, 214 and June 3, 215. For consistency, only Manitoba residents who were registered with MHHLS for health care coverage were included. In the influenza season, there were 1,75 laboratory-confirmed cases of influenza A and 217 laboratory-confirmed cases of influenza B reported in Manitoba. Of the 1,75 influenza A cases, 615 (57%) were influenza A(unsubtyped), 338 (31%) were influenza A(H3), and 119 (11%) were influenza A(H3N2). Influenza A Sporadic cases of influenza A started to appear in Week 39 (September 21 27, 214) and the last case was reported in Week 18 (May 3 9, 215); the seasonal epidemic began in Week 49 (November 3 December 6, 214) and peaked in Week 53 (December 28, 214 January 3, 215). Compared to previous influenza A seasons since the 29 pandemic season, the season progressed rapidly reaching an earlier and higher peak within four weeks after the epidemic began (Figure 4). Page 1 of 26

11 epireport INFLUENZA Figure 4 Laboratory-confirmed influenza A cases by week and season It is known that peak transmission varies widely from year to year. To compare the current season on a weekly basis to previous seasons, the curves of weekly influenza A cases in previous influenza A predominant seasons were aligned on the peak of the same curve in Subsequently, the historical average number (95% confidence intervals) of influenza A cases by each week were calculated (Figure 5). It is evident that there were significantly more cases each week between Week 52 (December 21 27, 214) and Week 4 (January 25 31, 215) than the average of previous influenza A seasons. Specifically, 233 cases were reported in Week 53 in compared to 17, the average of previous influenza A predominant seasons in the peak week /215 Historical average (95%CI) Figure 5 Influenza A cases by week in and historical average Older people were affected the most this season. Generally, there were more confirmed cases and higher incidence rates among people over the age of 5 than among people under the age of 5 (Figure 6). Note that 54% of all reported influenza A cases occurred in adults over the age of 7. The highest number of cases and the highest incidence rate occurred among those over the age of 8. Specifically, 439 cases (4.9%) were reported among people over the age of 8, which resulted in an Page 11 of 26

12 Cases Cases /1, population epireport INFLUENZA incidence rate of 87 cases per 1, population. 2 The second highest incidence rate was observed among children under the age of one (219 cases per 1, population), but there were only 36 cases in this age group. Compared to the four previous influenza A seasons (including , the last influenza A(H3N2) predominant season), the incidence rate among older people, especially those over the age of 8, was substantially higher in Influenza A cases in Rate in Rate in Rate in Rate in Rate in < > Figure 6 Incidence rate (/1,) of influenza A by age group and season Influenza B Though influenza B cases occurred sporadically throughout the season, the epidemic started when the influenza A activity level decreased and peaked in Week 13 (March 29 April 4, 215), around three months after the peak of influenza A (Figure 7). After Week 19 (May 1 16, 215), the influenza B activity level started to decrease. Compared to the four previous influenza B seasons, the peak of laboratory confirmed cases of influenza B in was higher than peaks in influenza A predominant seasons but lower than the peak in , the last influenza B predominant season Figure 7 Laboratory-confirmed influenza B cases by week and season 2 Population counts or denominators in this report were based on all registered residents with MHHLS on June 1, 214 Page 12 of 26

13 Cases Cases/1, epireport INFLUENZA A similar method was used to calculate the historical average number (95% confidence intervals) of influenza B cases by each week (Figure 8). In , the weekly number of influenza B cases was significantly higher than the historical average in most weeks during the epidemic /215 Historical average (95% CIs) Figure 8 Influenza B cases by week in and historical average Unlike influenza A, influenza B affected younger populations. This season, most influenza B cases (79%) were under the age of 6 (Figure 9). However, similar to influenza A, the highest incidence rate was still among older adults over 8 years of age (53 cases per 1, population) and followed by children under one (49 cases per 1, population). It is noticeable that the incidence rates among adults above 3 years of age in were higher than in previous influenza B seasons Influenza B cases in Rate in Rate in Rate in Rate in Rate in Figure 9 Incidence rate (/1,) of influenza B by age group and season RHAs Differences among RHAs were observed in the season (Table 1). The highest incidence rate of influenza A was observed in Northern Health Region (162 cases per 1, population), followed by Prairie Mountain Health (152 cases per 1, population). The lowest incidence rate was recorded in Winnipeg RHA (58 cases per 1, population). The incidence rate of influenza B was relatively low in all RHAs. The highest incidence rate of influenza B also occurred in Northern Page 13 of 26

14 Cases/1, epireport INFLUENZA Health Region (39 cases per 1, population), followed by Interlake-Eastern RHA (33 cases per 1, population). Table 1 Incidence rate (/1,) of influenza A and B by RHA in RHA Influenza A Influenza B N Rate Cases/1, N Rate Cases/1, Winnipeg Southern Interlake-Eastern Prairie Mountain Northern Manitoba Figure 1 compares the incidence rate of influenza A in to the last four influenza A seasons among RHAs. Generally, the incidence rate in Winnipeg RHA was the lowest in all seasons except for in , which was an influenza B predominant season. It is noted that in Northern Health Region, the incidence rate was consistently higher than other RHAs. However, it decreased significantly from (31 cases per 1, population) to (162 cases per1, population). A reliable incidence rate of influenza B for each RHA by season could not be calculated due to small numbers Winnipeg Southern Interlake-Eastern Prairie Mountain Northern Figure 1 Incidence rate (/1,) of influenza A by region and season Hospitalizations, ICU Admissions and Deaths To monitor the severity and burden of illness associated with influenza, each influenza season, RHAs are asked to submit a line list of hospitalizations, ICU admissions, and deaths to E&S at MHHLS on a weekly basis, which includes the lab requisition number, age, reporting RHA, and type/subtype of influenza. Aggregate numbers of hospitalizations, ICU admissions and deaths are also reported to PHAC for national surveillance on a weekly basis. Hospitalized cases are defined as Manitoba residents with laboratory-confirmed influenza admitted to a hospital located within the reporting RHA. Meanwhile, the reason for hospitalization, ICU admission, or the cause of death does not have to be attributable to influenza. Instead, a temporal association Page 14 of 26

15 epireport INFLUENZA with a positive influenza laboratory result is sufficient for reporting. Influenza associated deaths may also be reported from other sources, including: 1. Chief Medical Examiner; 2. MOHs in RHAs; and 3. Infection Control Practitioners in long-term care facilities. The number of severe outcomes associated with laboratory-confirmed influenza diagnosis in was the highest since the 29 pandemic season. There were 35 hospitalizations associated with the influenza diagnosis, among which 62 were ICU admissions (Table 2). A total of 48 influenza associated deaths were also reported, 26 of which occurred in hospitals and 18 in personal care homes. The majority of the hospitalizations (n=32, 86%), ICU admissions (n=46, 74%), and deaths (n=44, 82%) were associated with influenza A. Table 2 Hospitalizations, ICU admissions and deaths by influenza type in Type/subtype Hospitalizations ICU admissions Deaths N % N % N % Influenza A(unsubtyped) % % % Influenza A(H3) % % % Influenza A(H3N2) % 2 3.2% % Influenza B % % 4 8.3% Total The influenza A associated hospital admissions occurred between Week 47 (November 16 22, 214) and Week 21 (May 24 3, 215). They mostly occurred during the peak weeks of influenza A (69 admissions in Week 53, 62 admissions in Week 1, and 72 admissions in Week 2) and dropped to 4 admissions in Week 3 (January 18 24, 215). Among those hospitalized cases, the ICU admissions occurred between Week 52 (December 21 27, 215) and Week 2 (May 17 23, 215). Of the 48 influenza associated deaths, the highest number (n=8) occurred in Week 53 (December 28, 214 January 3, 215) and Week 1 (January 4 1, 215). Note that after the influenza A epidemic, since Week 5 (February 1 7, 215), the severe outcomes associated with influenza, mostly influenza B, continued at a low level and were prolonged until the end of May 215 (Figure 11) Deaths (Flu B) in ICU admissions (Flu B) in Hospitalizations (Flu B) in Deaths (Flu A) in ICU admissions (Flu A) in Hospitalizations (Flu A) in Hospitalizations in Hospitalizations in Figure 11 Influenza associated hospitalizations, ICU admissions, and deaths by week in Page 15 of 26

16 Cases Cases/1, epireport INFLUENZA In , a large proportion of influenza A cases were reported to have influenza associated severe diseases. In total, 28% of all influenza A cases were admitted to hospital, among which 15% were admitted to ICU, and 4% deceased. Age was a significant factor linked to severe influenza associated outcomes. Generally, more influenza A associated hospitalizations, ICU admissions, and deaths were observed in an older age group (Figure 12). Most (n=184) or 7% of the influenza A associated hospitalizations occurred among those over the age of 7. Of the 44 influenza A associated deaths, the majority (n=38) or 86% occurred among those over the age of 7. The hospitalization rates among different age groups are also presented in Figure 12. Older people were more likely to have influenza A associated hospitalizations in , especially those over 8 years of age (226 hospitalizations per 1, population). Young children under the age of one were also likely to be hospitalized with influenza A diagnosis (97 hospitalizations per 1, population). The increased risk for influenza associated severe outcomes among older adults is a combination of factors including the circulating influenza A(H3N2) strain linked to more severe disease, a large volume of outbreaks in long-term care facilities, and low vaccine effectiveness this season Hospitalizations ICU admissions Deaths Hospitalization rate Figure 12 Influenza A associated hospitalizations, ICU admissions, and deaths by age group in Compared to influenza A, influenza B was associated with fewer severe outcomes in , especially deaths (48 hospitalizations, 16 ICU admissions, and four deaths). Overall, 22% of all influenza B cases were admitted to hospitals (among which 33.3% were admitted to ICUs) and only 2% deceased. Hospital and ICU admissions associated with influenza B occurred more frequently among younger populations under the age of 6 (Figure 13). However, all four influenza B associated deaths occurred among people over 6 years of age. Page 16 of 26

17 Cases Cases/1, epireport INFLUENZA Hospitalizations ICU admissions Deaths Hospitalization rate Figure 13 Influenza B associated hospitalizations, ICU admissions, and deaths by age group in Laboratory-confirmed Outbreaks As outlined in Manitoba s Communicable Disease Management Protocol Manual on Epidemiological Investigation of Outbreaks 3, the common definition of an outbreak is: The occurrence in a community or region of cases of an illness with a frequency clearly in excess of normal expectancy. The number of cases indicating presence of an outbreak will vary according to the infectious agent, size and type of population exposed, previous experience or lack of exposure to the disease, and time and place of occurrence. Therefore, the status of an outbreak is relative to the usual frequency of the disease in the same area, among the same population, at the same season of the year. 4 Each influenza season, reports of suspected/confirmed influenza outbreaks are directed to E&S by a phone call/ from public health staff within RHAs or from CPL advising the assignment of an outbreak code. Outbreaks can also be submitted to E&S by completing an outbreak summary report. In this report, only laboratory-confirmed reports of institutional influenza outbreaks are included, which means each outbreak had at least one laboratory confirmed case. Between June 29, 214 and July 4, 215, there were 15 outbreaks of laboratory-confirmed influenza reported in Manitoba: 93 outbreaks of influenza A, 11 outbreaks of influenza B, and one mixed outbreak of influenza A and B. Outbreaks were reported in all RHAs: 51 in Winnipeg RHA, 17 in Southern Health-Santé Sud, 15 in Interlake-Eastern RHA, 2 in Prairie Mountain Health, and two in Northern Health Region. The majority of these outbreaks occurred in long-term care facilities. Similar to other indicators, the number of outbreaks by week increased in alignment with the laboratory reports of influenza A (Figure 14) with a peak in Week 53 (December 28, 214 January 3, 215) Chin, James (Editor). Control of Communicable Disease Manual. American Public Health Association, Washington DC, 2. Page 17 of 26

18 Outbreaks epireport INFLUENZA Influenza A and B Influenza B Influenza A Figure 14 Outbreaks of influenza A and B by week in Immunizations Uptake Influenza immunization data are routinely extracted from the Manitoba Immunization Monitoring System (MIMS), which contains information related to an immunization event including type of vaccine administered, date of administration and the service provider. Seasonal influenza immunization events in were captured in MIMS in one of three ways: Immunizations administered by physicians were entered into MIMS via the physician billing system. Immunizations administered by pharmacists were submitted to MHHLS and were manually entered into MIMS by data entry staff at MHHLS. Immunizations administered by all other providers including public health nurses were recorded by data entry staff in the RHAs. In , the seasonal influenza vaccine (inactivated influenza vaccine) was available free-ofcharge to all Manitobans over 6 months of age. As with previous years, MHHLS conducted a targeted, universal program with focus on those at increased risk of serious illness from influenza, their caregivers and close contacts including: Seniors aged 65 or older Residents of a personal care home or long-term care facility Health care workers and first responders Children 6 to 59 months of age Individuals of Aboriginal ancestry Those with chronic illness, such as: Cardiac or pulmonary disorders (including bronchopulmonary dysplasia, cystic fibrosis and asthma); Diabetes mellitus and other metabolic disorders; Cancer, immune compromising conditions (due to underlying disease and/or therapy); Renal disease; Page 18 of 26

19 epireport INFLUENZA Anemia or hemoglobinopathy; Conditions that compromise the management of respiratory secretions and are associated with an increased risk of aspiration; and, Children 6 months to adolescents 18 years of age on long-term acetylsalicylic acid (i.e. Aspirin) therapy People who are severely overweight or obese Healthy pregnant women In addition, international students, visitors and newcomers were eligible to receive the flu vaccine free-of-charge regardless of third party insurance and/or MHHLS coverage. As per the World Health Organization (WHO), all seasonal trivalent influenza vaccines for the season in the northern hemisphere contained: an A/California/7/29 (H1N1)pdm9-like virus; an A/Texas/5/212 (H3N2)-like virus; a B/Massachusetts/2/212-like virus. This was the first year that the live attenuated influenza vaccine, FluMist (nasal spray), was also included in Manitoba s influenza immunization program. FluMist was offered to children and youth 2 to 17 years of age. Initially, FluMist Quadrivalent was offered in Manitoba, which provided protection against an additional influenza B strain, the B/Brisbane/6/28-like virus. As a result of manufacturers production delays, FluMist Trivalent was offered in Manitoba for the remainder of the season. All seasonal influenza immunizations entered in MIMS were captured using tariff codes including 8791, 8969, and By end of March, 215, it was found that the highest uptake was among Manitobans aged 65 years and over (54.8%) followed by the 2 year-old age group (2.6%), the year-old age group (17.1%), and the 3 18 year-old age group (12.2%). This end of season report analyzed the immunization data in more detail. Between July 1, 214 and June 3, 215, a total of 297,489 vaccine doses were administered to 291,567 people. Only four doses were not publicly funded. Particularly, 297,92 doses were administered to 291,249 people between September 1, 214 and March 31, 215, the influenza immunization season. In this report, only the doses delivered during the immunization season were analyzed. The overall influenza vaccine uptake rate in Manitoba was 22.3% in the influenza immunization season. The highest uptake was among people over 8 years of age (64%) followed by people aged between 7 and 79 years (57%) and those aged between 6 and 69 years (42%). The lowest uptake, around 8%, occurred among those aged between 15 and 24 years (Figure 15). Page 19 of 26

20 Vaccine uptake % Doses epireport INFLUENZA , Doses Vaccination Rate 18, 16, 14, , 1, 8, 2. 6, 1. 4, 2, Figure 15 Influenza immunization uptake rate (%) by age group in There were differences in vaccine uptake among RHAs (Table 3). The highest uptake was observed in Winnipeg RHA (25%) and the lowest in Southern Health-Santé Sud (16%). Table 3 Influenza immunization uptake rate (%) by region and age group in Age Winnipeg Southern Interlake Prairie Eastern Mountain Northern Manitoba Total Differences in immunization uptake between RHAs were more evident among children under the age of one (Figure 16). Compared to Winnipeg RHA (25%), vaccine uptake among children under one was much lower in Southern Health-Santé Sud (7%), Prairie-Mountain Health (8%), Northern Health Region (9%), and Interlake-Eastern RHA (15%). There were also inconsistencies across age groups. In Northern Health Region, people under 1 years of age and over 6 years of age had lower vaccine uptake rates compared to people within the same age groups in Winnipeg RHA. However, people between 1 and 6 years of age in Northern Health Region had a similar vaccine uptake rate compared to people in the same age group in Winnipeg RHA. Page 2 of 26

21 Vaccine uptake % epireport INFLUENZA Winnipeg Southern Interlake-Eastern Prairie-Mountain Northern Figure 16 Influenza immunization uptake rate (%) by region and age group in Providers Similar to previous influenza immunization seasons, public health nurses and physicians in were two major groups of immunization service providers. Each group administered almost 38% of all doses. Newly eligible to administer seasonal influenza vaccines, pharmacists delivered a substantial amount of service, 49,642 doses or 17% of the total administered in Manitoba during the immunization season (Table 4). Table 4 Influenza vaccine doses by provider type and month in Month Public Nurse Physician Pharmacist Other All (% of total) Sept (.2%) Oct ,724 29,848 2,88 13,94 145,356 (48.9%) Nov ,8 58,435 23,783 9, ,654 (39.3%) Dec ,3 16,499 3,787 1,78 24,394 (8.2%) Jan ,77 4,765 1, ,911 (2.7%) Feb , ,718 (.6%) Mar (.2%) Total 111, ,332 49,642 24, ,92 (%) (37.5%) (37.5%) (16.7%) (8.4%) Almost 9% of all doses were administered in October and November of 214. However, providers distributed their service differently time-wise. Public health nurses delivered more doses in October (n=8,724) than in November (n=25,8) and physicians delivered more in November (n=58,435) than in October (n=29,848). In comparison, pharmacists delivered a similar amount of doses, 29,848 and 23,783 respectively, in each of the two months (Figure 17). Due to manufactory delays, Manitoba started to receive its influenza vaccine supply intermittently since mid-october as opposed to mid- September when influenza vaccines are expected to be received each year. Page 21 of 26

22 Doses epireport INFLUENZA , 14, 12, 1, Public Nurse Physician Pharmacist Other 8, 6, 4, 2, September October November December January February March Figure 17 Influenza vaccine doses by provider type and month in The distribution of service by each provider also varied among age groups of clients (Table 5). Public health nurses were the major service providers among all Manitoba residents above the age of one, providing nearly 38% of all doses. Physicians were the major service providers among children aged between 6 months and four years. Especially, more than three quarters of the doses administered to those less than one year of age were delivered by physicians. Pharmacists were important service providers among people over seven years of age, administering almost 17% of all doses. Table 5 Influenza vaccine doses (%) by provider type and client age group in Age Physician Public Nurse Pharmacist* Other Total 3,472 (76.16%) 925 (2.29%) 5 (.11%) 157 (3.44%) 4, ,941 (6.6%) 5,37 (36.7%) 48 (.32%) 527 (3.54%) 14, ,459 (39.87%) 11,67 (44.24%) 3,438 (13.11%) 73 (2.78%) 26, ,292 (34.4%) 52,229 (36.45%) 27,685 (19.32%) 14,88 (9.83%) 143, ,168 (36.23%) 41,163 (38.7%) 18,466 (17.8%) 9,322 (8.62%) 18,119 *As per The Manitoba Pharmaceutical Act and Regulations, pharmacists are authorized to administer seasonal influenza immunizations to people 7 years of age and older. Adverse Events Following Immunization (AEFI) Per The Food and Drugs Act and Regulations, vaccine manufacturers are required to report to PHAC all serious AEFI reports with vaccines for which they are the Market Authorization Holder within 15 days of knowledge of their occurrence. No other legal requirement for reporting AEFI exists nationally. An AEFI is reportable under The Public Health Act as prescribed in the Immunization Regulation (C.C.S.M. c.p21) if it is temporally associated with an immunizing agent, cannot be attributed to a coexisting condition, and if it meets at least one of the following criteria: a. the event is life-threatening, could result in permanent disability, requires hospitalization or urgent medical attention, or for any other reason is considered to be of a serious nature; b. the event is unusual or unexpected, including, without limitation, a. an event that has not been previously identified, or Page 22 of 26

23 epireport INFLUENZA b. an event that has been previously identified but is being reported at an increased frequency; c. at the time of the report there is nothing in the patient s medical history such as a recent disease or illness, or the taking of medication that could explain the event. Health care professionals who become aware of reportable adverse events are to report them within 7 days by completing and faxing the AEFI form 5 to their regional MOHs. A total of 39 influenza vaccine related AEFI reports were received during the immunization season, which were dated between October 14, 214 and January 29, 215. Overall, the incidence rate of AEFI was 13.1 episodes per 1, doses administered. By age group, the highest incidence rate of AEFI occurred among children under one year of age (Table 6). Table 6 Adverse events following influenza immunization by age group in Age N group Rate (/1, doses) The majority of reported AEFIs were for allergic or allergic-like reactions (n=22 or 41%), followed by local reactions (n=14 or 26%). There was one report of anaphylaxis, and two reports of oculorespiratory syndrome (Table 7). Because some individuals experienced more than one reaction in a single episode, there was a greater number of reactions (n=54) than reports submitted (n=39). Table 7 Types of adverse events following influenza immunization in Adverse event N % Local reaction % Allergic or allergic-like event % Anaphylaxis 1 1.9% Oculo-respiratory syndrome 2 3.7% Neurologic events 4 7.4% Other defined event of interest % Total 54 Various levels of care were required for these AEFIs. Only eight individuals with AEFIs required an emergency visit (21%) and the rest required either low levels of care or no care (Table 8). No AEFIs were reported to result in death (Table 8). At the time of reporting, almost half of the individuals experiencing AEFIs had fully recovered (n=18 or 46%). 5 Page 23 of 26

24 epireport INFLUENZA Table 8 Levels of care required and outcomes for adverse events following influenza immunization in Level of care required by patients N % Patient outcome N % None % Fully recovered % Telephone advice from health 9 Not yet recovered % professional 23.1% Permanent Non-urgent visit 13.% 33.3% disability Emergency visit 8 2.5% Death.% Hospitalization.% Unknown 3 7.7% Prolongation of existing hospitalization.% Total 39 Antiviral Dispensing The daily units of antiviral drug, Oseltamivir (Tamiflu ), dispensed to Manitoba residents during the influenza season are obtained on a weekly basis from Drug Programs Information Network (DPIN) since October 1 during each influenza season. Only drugs dispensed from community retail pharmacies could be included in this report and those dispensed to in-patients or through nursing stations could not be included due to lack of data. Between October 1, 214 and June 6, 215, a total of 2,592 units of Oseltamivir were dispensed from community retail pharmacies. The units of Osteltamivir dispensed each week closely paralleled the numbers of laboratory-confirmed influenza cases (Figure 18) with a one-week delayed peak in Week 1 (January 4 1, 215). Compared to the season, considerably more units of Oseltamivir were dispensed in December and January between Week 5 (December 7 13, 214) and Week 5 (February 1 7, 215) Influenza Cases in Units in Units in Figure 18 Units of Oseltamivir dispensed by week in Strain Characterization and Antiviral Resistance Influenza and Respiratory Viruses Section of National Microbiology Laboratory (NML) undertakes enhanced surveillance, investigations, and research on influenza and other respiratory pathogens. Additionally, NML develops, evaluates, and improves new molecular techniques and reagents for Page 24 of 26

25 epireport INFLUENZA early detection and identification of potential epidemic and pandemic influenza strains and other new emerging respiratory viruses. As a routine practice, NML also antigenically characterizes influenza viruses received from Canadian laboratories. In Manitoba, a random sample of positive influenza specimens isolated by culture is referred from CPL to NML for strain characterization. Routine testing for antiviral resistance is also performed by NML. The aggregate level information is then shared with provinces and territories on a weekly basis. In Canada, the season was predominated by the A/Switzerland/ /213-like strain, which was related to, but antigenically and genetically distinguishable from, the A/Texas/5/212 vaccine virus. Influenza viruses of the B/Yamagata lineage predominated among the influenza B viruses detected, which were similar to B/Massachusetts/2/12, the vaccine virus included in the trivalent vaccines. Between September 1, 214 and July 4, 215, NML reported that it had antigenically characterized 36 influenza viruses from Manitoba (Table 9). All 1 influenza A (H3N2) viruses characterized were antigenically similar to A/Switzerland/ /213 and the 26 influenza B viruses were antigenically related to B/Massachusetts/2/12. Table 9 Strain characterization of influenza isolates in Manitoba and Canada in Influenza Strain Canada Manitoba A/Switzerland/ /213(H3N2)-like 26 1 A/Texas/5/212(H3N2)-like 6 A/California/7/9(H1N1)-like 21 B/Massachusetts/2/12-like B/Brisbane/6/28-like 98 Note. Reports between September 1, 214 and July 4, 215 Between September 1, 214 and July 4, 215, NML reported that all influenza isolates submitted from Manitoba were susceptible to Oseltamivir and Zanamivir, although nationally one influenza A(H3N2) isolate demonstrated resistance to Oseltamivir (Tables 1). All Manitoba viruses tested were resistant to Amantadine. Table 1 Antiviral resistance of influenza isolates in Manitoba and Canada in Virus Oseltamivir Zanamivir Amantadine Sensitiv Resistant Sensitive Resistant Resistant e Sensitiv e Manitoba A(H3N2) A(H1N1) B N/A N/A Canada A(H3N2) A(H1N1) B N/A N/A Note. Reports between September 1, 214 and July 4, 215 Discussion Influenza surveillance is inherently biased towards more severe outcomes and this annual report serves to characterize severe cases and to monitor broad trends. The burden of influenza is likely underestimated due to the lack of a true denominator for all individuals infected because not all Page 25 of 26

26 epireport INFLUENZA individuals experiencing symptoms will seek medical attention and not all clinicians will routinely test cases of ILI for influenza. Additionally, during influenza seasons, factors such as circulating strains, vaccine formulation, and heightened public awareness can result in less or more healthseeking behaviours, which might influence findings. In the influenza season, Manitoba experienced the highest morbidity and mortality since the 29 pandemic season. As routine reporting of laboratory-confirmed influenza cases began in 29 and there have been only two influenza A(H3N2) predominant seasons including the season, it is difficult to determine whether the increased laboratory activity this season was higher than expected in an influenza A(H3N2) predominant season. The predominant circulating influenza A(H3N2) strain was a major contributor to the increased morbidity and mortality in the season, especially among older populations. In the past, influenza A(H3N2) predominant seasons have been linked to more severe illness and higher mortality, especially among older people and young children, compared to influenza A(H1N1) or influenza B predominant seasons. The severity in was evidenced by a number of influenza associated hospitalizations, ICU admissions, and deaths that was higher than in any of the previous seasons. The vaccine mismatch was another major contributor to the severity of influenza in The predominant circulating influenza A(H3N2) strain was antigenically distinct from the northern hemisphere vaccine, which resulted in near zero vaccine effectiveness against the circulating influenza A(H3N2) strain. The mid-season estimate of vaccine effectiveness in Canada was -8% (95% confidence interval: -5% 23%) against influenza A(H3N2) virus infections in patients with medically attended ILI 6. In the United States, the seasonal vaccine effectiveness estimate was 18% against influenza A(H3N2) virus infections (95% confidence interval: 6% 29%) 7. The influenza activity observed by two syndromic indicators under surveillance in , ILI consultations and influenza related calls to Health Links Info Santé, paralleled the activity observed by the laboratory confirmed influenza infections instead of peaking prior, a trend observed in previous seasons. To prepare for future influenza seasons like , more indicators that could detect the increase of influenza activity should be explored and tested. 6 Skowronski, D.M. et al. (215). Interim estimates of 214/15 vaccine effectiveness against influenza A(H3N2) from Canada's Sentinel Physician Surveillance Network, January 215. Euro Surveillance, 2(4). 7 CDC Presents Updated Estimates of Flu Vaccine Effectiveness for the Season Page 26 of 26

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